BY ORDER OF THE AIR FORCE PAMPHLET 91-215 SECRETARY ...

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A2.B.11.6. RESOURCES. As noted above there are many inspection criteria, checklists and related job aids available commercially and within the Air Force. Many of these have been tailored for specific types of organizations and activities. The local safety office can be a valuable resource in the development of inspection and survey criteria and can provide technical support in the form of interpretations, procedural guidance, and correlation of inspection data with other like units. A2.B.11.7. COMMENTS. Inspections and surveys have long track records of success in detecting hazards and reducing risk. They have been criticized as being inconsistent with modern management practice because they are a form of “downstream” quality control. By the time a hazard is detected, it already exists and may have already have caused loss. The ORM approach to inspections emphasizes focus on the higher risks within the organization and emphasizes the use of management and safety program surveys that detect the underlying root causes of hazards rather than the hazards themselves. Properly designed and conducted, inspections and surveys retain a vital place in an effective risk management process. A2.B.11.8. EXAMPLES. Conventional inspections normally involve seeking and recording unsafe acts/conditions. The number of unsafe acts/conditions can be the result of either the number of unsafe acts/conditions in the organization or possibly the extent of effort extended to find hazards. Conventional inspections can never be a reliable indicator of the extent of risk. To change the nature of the process to reliably indicate the extent of risk, it is often only necessary to record the total number of observations made of key behaviors and then determine the number of unsafe behaviors. This yields a rate of “unsafeness” that is independent of the number of observations made. 74
A2.B.12. <strong>THE</strong> MISHAP/INCIDENT INVESTIGATION A2.B.12.1. FORMAL NAME. The mishap/incident investigation A2.B.12.2. ALTERNATIVE NAMES. The incident tool A2.B.12.3. PURPOSE. The traditional mishap investigation has the objective of determining the causes of a mishap so that these causes can be eliminated or mitigated. The ORM approach adds a new dimension to the traditional concept. ORM stresses the determination of the inadequacies in the risk management process that allowed the mishap cause factors to impact the organization. A mishap investigation therefore becomes primarily an investigation of the risk management process itself to determine if it can be strengthened to control the risk factors that led to the mishap. The question now is not only what is the cause, but also how could the cause exist in the context of the risk management process. A2.B.12.4. APPLICATION. Ideally all mishaps and incidents should be thoroughly investigated. Unfortunately, mishap investigations are expensive. Ideally the organization should have a process to select mishaps and incidents against which to allocate limited investigative resources. Severity is a relevant factor in this decision, but it should not be the dominate factor that it is in most investigation systems today. Simply because a mishap was serious does not mean that it is worth in-depth investigation. On the other hand, what appears on the surface to be a minor incident may be a gold mine of data regarding the risk management process. An effective risk manager will be able to sort out the opportunities and direct the investigative effort where it will produce the best return on investment. A2.B.12.5. METHOD. Both the technical and management processes involved in a mishap/incident investigation are complex beyond the scope of this publication. Detailed guidance is provided in Air Force publications. From a risk management perspective the key is to investigate the risk management issues that are the cause of the direct mishap causes. Only by correcting these root risk management cause factors will the mishap investigation process be fully effective. A2.B.12.6. RESOURCES. Most safety offices have personnel trained in detail in mishap investigation processes. They can serve as consultants in this critical process. Policy and procedures to follow in the process of investigating and reporting mishaps is contained in AFI <strong>91</strong>-204, Safety Investigations and Reports, and applicable supplements. A2.B.12.7. COMMENTS. Mishap and incident investigations have a long track record of success in preventing future mishaps. A2.B.12.8. EXAMPLES. Base safety offices can provide guidance on the investigation and reporting process and on the use of the data for hazard identification. 75
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BY ORDER OF THE AIR FORCE PAMPHLET
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Figure 14. Levels of Command Involv
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levels while preserving assets and
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Section B—The ORM Process 5. Intr
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8.2. Identified Risk is risk that h
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labeled with its significance (high
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Page 113 and 114: Attachment 7 SUPERVISE AND REVIEW D
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BY ORDER OF THE AIR FORCE PAMPHLET 91-215 SECRETARY ...

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